Fotonovelas and Anglo designs in health communications for

Transcription

ISSN: 2153-9480. Volume 3, Number 1. December - 2012
Fotonovelas and Anglo designs in health
communications for Spanish-speaking residents
along the U.S.-Mexico border
Barry Thatcher
New Mexico State University, USA
Abstract
This study compares the intercultural instructional designs, based on eight intercultural value
sets, of two types of health communications for Spanish-speaking U.S.-Mexico border
populations. The first design is the fotonovela, or photo drama pamphlet, an approach that is
well developed in Latin America and modeled after the famous Latin American television soap
opera genre of telenovelas. This design dramatizes health information in culturally appropriate
ways. The second design is Anglo dominant, representing predominant rhetorical and cultural
preferences of the United States. Grounded in a Texas Health Equity project, the research team
created a fotonovela for septic maintenance for border colonias. The team then compared the
preference and effectiveness of the fotonovela to an existing EPA manual that reflected the
Anglo dominant design, asking Spanish-speaking residents on the U.S. side of the U.S.-Mexico
border their preferences for instructional designs. The results showed a very strong correlation
between the fotonovela/Anglo designs and birthplace, language proficiency, and education.
These results suggest that professional communicators need to move beyond demographics in
designing their health communications for Spanish-speaking audiences. Instead, the study
proposes a typology of five Hispanic/Latino identities for the U.S.-Mexico border, which helps
professional communicators better assess rhetoric preferences and traditions.
Introduction and problem statement
Now, it is widely recognized that medicine, health care, and health communications are not
universal but are intimately connected to local cultures and medical traditions (Purnell, 2009).
Consequently, health and medical services are best delivered using the cultural and
communication patterns of the patients (see, for example, Purnell, 2009; Tseng & Streltzer,
2008). This move towards culturally competent health care is so critical to reducing health
disparities in the United States that it is mandated at the federal and many state levels
(hrsa.gov/culturalcompetence). Not surprisingly, much research has focused on improving
Thatcher: Fotonovelas and Anglo designs in health communications for
Spanish-speaking residents along the U.S.-Mexico border
health disparities using culturally competent health care. This is especially true with Latinos or
Hispanics (hablamosjuntos.org), which make up the largest U.S. minority. For example, new
critical research has focused on the roles of Spanish translators and new multimedia forms to
bridge cultural and linguistic differences for Hispanic populations (Angelelli & Jacobson, 2009).
A critical component of culturally competent health care is using culturally sensitive
communications (hrsa.gov/culturalcompetence) to deliver that health care. This simply means
matching the purpose, format, information needs, and style of the communication to the
communicative expectations of the target audience. For example, Givaudan et al. (2005) have
developed specific strategies for delivering culturally sensitive communications for Hispanic
audiences. These include understand the cultural forms of Latino communications; developing
texts and formats that match these forms; using appropriate language and vocabulary;
understanding the issues of health care most relevant to Latinos; and the critical variables for
promoting health behavior. Much of the effort in developing these culturally sensitive materials
focuses on the inadequacy of traditional methods of assessing health communications, especially
those involving readability formulas (Contreras, 1999—cited in Givaudan). In other words, just
like health care services, the readability or effectiveness of health communications has to be
examined in light of the cultural expectations of the audience.
Concurrent with this work in culturally competent health care is the significant focus on health
literacy, which is generally defined as understanding, accessing, and appropriately using health
related tools and services. The field of health literacy is very broad (Shohet, 2004),
encompassing many approaches, theories, methods, and practices. Much has been written and
researched about health literacy, including, for example, the special edition of health literacy in
the Journal of Health Communications. Further, the Agency for Healthcare Research and
Quality just published an extensive review of health literacy research, summarizing the results of
over 139 studies. Many researchers argue that health literacy patterns and practices are
culturally dependent and thus vary, often significantly, across cultures (Singleton & Krause,
2009; Purnell & Paulanka, 2008). The question remains, however: how does health literacy vary
across cultures and why?
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Despite the efforts to address health literacy in intercultural contexts (Olney, et al, 2007;
hablamosjuntos.org), there is still a large gap in theory, methods, and practice, most of which is
due to the inability of researchers to see the connection between rhetorical and cultural patterns.
To exemplify this gap, I present in Table 1, two forms of health literacy that are common on the
U.S.-Mexico border: the one on the left is a fotonovela, while on the right is what I have defined
as an Anglo-dominant approach.
Rhetoric, Professional Communication, and Globalization
December, 2012, Volume 3, Number 1, 74-109.
Table 1
Two manual designs for cholesterol and cardiovascular health
Fotonovela Literacy Patterns
An Ounce of Prevention: A Guide to Heart Health (NIH,
National Heart and Blood Institute; 4 of 24 p.)
U.S.-Generic, Anglo Literacy Patterns
High Blood Cholesterol: What you Need to Know (NIH,
National Heart and Blood Institute; 4 of 6 p.)
Although both manuals describe heart health, the stark differences show that simply translating
the generic, Anglo-dominant manuals into Spanish will not meet the cultural expectations of
those who prefer the fotonovela design. In other words, the cultural characteristics of the
fotonovela are evident in the way it is organized and presented; culture is much deeper than
translation. But how can we conceptualize this relationship between culture and
communication? And how does this conception help us understand and design materials for
intercultural health situations?
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This fotonovela was written by experts in Latino health. It uses a family situation, games, and
drama to explain heart health, an approach that corresponds well to Latino cultural values
(Hinojosa, et al, 2011; Albert, 1996). The Anglo or generic design assumes an analytical,
objective, and individual approach, which reflects broad U.S. cultural values (Thatcher, 2012).
Although popular in Latin America, the fotonovela design is rare in U.S. health care materials
(Olney, et al, 2007). For example, the Agency for Health Research and Quality’s 2011
Systematic Review of health literacy barely mentions fotonovelas and its consumer website
shows all Spanish-speaking materials using the Anglo design (ahrq.gov/consumer/).
The problem is that current approaches in health literacy and cultural competency cannot assess
much beyond translation and language proficiency. First, since culture is often defined and
operationalized so broadly, valid and reliable research and practice are difficult. For example,
the U.S. Office of Minority Health defines culture as “the thoughts, communications, actions,
customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups”
(minorityhealth.hhs.gov). This catch-all approach has such a great variety of multiple and
complexly related variables, units of analysis, and potential interactions that developing and
assessing relevant intercultural differences are difficult, if not impossible (Lucy, 1996; Bhawuk
& Triandis, 1996; House, et al., 2005; Hofstede, 2010; Thatcher, 2012). Instead, researchers
need to create a universal frame of relevant and measurable variables that both cultures share and
then embed cultural differences in the shared frame, much as described later in the onion model.
In addition to relevancy and broadness, this catch-all definition is often saddled to a narrow view
of communication that is based on translation clarity and language proficiency. Defined as the
“window-pane” theory of communication (Miller, 1979), this view assumes that if the words or
translation are polished well, the audience will understand. For example, most Spanish health
literacy assessment tools are word-based, such as the REALM-SF and SAHLSA-50
(ahrq.gov/populations/sahlsatool.htm). When this narrow view of communication is connected
to a catch-all definition of culture, researchers cannot assess how cultural differences are
connected to literacy patterns in everyday sense-making activities (Barton, 2005; Bourdieu,
1999; Bakhtin, 1990). In short, this approach cannot assess why the Fotonovela and Anglodominant designs are so different and what those differences mean across groups of people.
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Third, because the gap between the catch-all definition of culture and narrow view of
communication is difficult to reconcile, most health care stakeholders are forced to rely on
demographic data to assess their intercultural communications needs. However, demographics
such as race and ethnicity do not reliably indicate cultural behavior (Hofstede, 2010; House, et
al, 2005), especially on the U.S.-Mexico border (Thatcher, 2012). For example, although the
2010 census shows a significant Hispanic population on the border, there is not a comparable
monolithic pattern in literacy expectations. In the following Table 2, Thatcher (forthcoming)
defines five complexly related Latino/Hispanic groups on the U.S.-Mexico border:
Table 2
Five transient points of stabilized identity along the U.S.-Mexico border.
4. Mexican
National (born
and educated
with
significant ties
to Mexico).
5. Crossborder &
bicultural:
Live and work
on both sides
border,
bilingual.
Relation to dominant Relation to U.S.
Mexican rhetorical
cultural and rhetorical
patterns (including
patterns (including
Spanish)
English)
 Remnants of
Significant and often
Spanish and Mexican overt assimilation of
culture especially in
deeply-rooted U.S.
family contexts.
cultural values.
 Limited function
in–and ambivalence
towards– Mexico.
Deeply connected to
Ambivalent and
Spanish and Mexican contextual: learn U.S.
cultural and
patterns sufficiently to
rhetorical patterns,
function in employment
but mostly oral
and education but reject
traditions and limited or ignore other U.S.
formal education.
values.
 Inherit Mexican
 Academic and
culture from parents
economic success are
and U.S. culture in
connected to English
education and work.
and U.S. traditions.
 Family Spanish.
 Strong affinities for
 Oral traditions,
U.S. cultural values of
especially as
universalism (level
children; written
playing field) and
traditions at school
individualism (relative
and in English.
independence),
 Strongly connects
 Often in U.S. to
Mexican rhetorical
improve economic and
and cultural
academic capacities.
traditions.
 Ambivalence about
 Ambivalence to
U.S. cultural and
U.S. dominance,
rhetorical traditions.
especially
 Academic English
historically.
with limited practice.
 See strengths and weaknesses in both U.S. and
Mexican cultural and rhetorical
traditionscapacity to leverage strengths and
minimize weaknesses according to situation.
 Feel both marginalized and empowered at the
same time, rooted but rootless.
 Most often hide bicultural and bilingual traits,
as compared to other groups.
Strategic positioning
among points of
identity in structured
contexts.
Can position as
Mexican identities with
Anglos, but readily
identifies with U.S and
distances from Mexico,
recent immigrant, or
G1.5 identities.
Can identify and
position as recent
immigrant, Mexican
national or perhaps
Mexican-American but
little capacity with U.S.
traditions.
 Can move between
professional contexts
with English and family
contexts with Spanish.
 Difficulty functioning
as Mexican national but
possible as recent
immigrant and usually
functioning as U.S.- or
Mexican-American.
 Often not reliably
informed about other
points of border identity
but can pass as recent
immigrant.
 Can view other
identities as sellouts or
culturally suspect.
 Adept at positioning
themselves as
Mexicans, MexicanAmericans, or U.S.Americans depending
on power dynamics.
 Ambivalence towards
Anglo-Americans.
Acculturation issues
for U.S.- and Englishsourced health
communications
 English dominant.
 Some affinity for
select cultural and
rhetorical traditions
from Mexico but
within a U.S. frame.
 Often limited
educational, English,
and literacy traditions.
 Strong oral and
interpersonal traditions
grounded in Mexican
rhetorical patterns.
 The most complex
group/sets of issues.
 Spanish/Mexican
repertoire in certain
rhetorical situations
and English/U.S. in
others.
 Great identity
complexities and
ambivalences.
 Strong educational
backgrounds.
 Most issues are
linguistic
(SpanishEnglish)
and contrastive
rhetoric.
 Strong general
rhetorical skills
because of innate
systematic nature of
their bicultural and
bilingual orientation.
 Can mix-up which
rhetorical strategies
are appropriate in
given contexts.
This article does not have the space to fully explore the definitions and expressions of these
identities, which is explored elsewhere (Thatcher, forthcoming), but generally following Vila
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Transient
Points of
Stabilized
Identities
1. MexicanAmerican
(3rd+
generation
U.S.-American
with Mexican
ancestry)
2. Recent
Immigrant
(less than 10
years in the
U.S. and from
Mexico or
Latin America)
3. Generation
1.5 (U.S.-born
but from
Mexican or
Latin
American
parents).
(2003), it explores the complexly structured and strategically changing border identities for the
five groups most likely classified as Hispanic/Latino by demographics.
This table explains much better than demographics why professional communicators cannot
assume that the five Latino groups would prefer the fotonovela as compared to the Anglo design.
Although designed for Latinos, the fotonovela fits better recent immigrants who generally bring
oral traditions and Mexican rhetorical expectations to rhetorical situations; the other four Latino
groups have ambivalent and complicated connections to the fotonovela and the Anglo pamphlet.
For example, Mexican-Americans most likely favor the Anglo version, while highly literate
Mexican nationals could be offended by the comic-book nature of the fotonovela but might not
connect well to the detached objectivity of the Anglo version. Generation 1.5 would be mixed
based on their hybrid literacies, and the cross-border group would most likely favor one design
over the other based on the rhetorical situation. However, because the very predominant
approach to health communications in the United States it to lump all five groups into one, we
simply do not know the connection between rhetorical expectations and instructional designs.
For effective intercultural health literacy, we need methods that assess and then match the
cultural orientations of people and literacy designs. Unfortunately, we cannot draw on the 14
CLAS Standards (Culturally and Linguistically Appropriate Services), which the U.S. Office of
Minority Health have developed for ensuring culturally appropriate health care services
(minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15). These standards are based on
the catch-all view of culture, window-pane theory of communication, and demographics.
Further, it is apparent that large, national health care agencies, providers, and technology
companies continually develop Spanish materials for the Hispanic audience that use Anglodominant designs (Thatcher, 2012; hablamosjuntos.org). Further, fotonovelas are usually
developed locally in specific contexts, minimally using existing materials and evidence-based
approaches. We simply don’t know of their effectiveness.
Drawing on intercultural research in communications (Samovar, Porter & McDaniel, 2009),
organizational behavior (Hofstede, 2010; House, et, al., 2005), and rhetoric and professional
communication (Varner & Beamer, 2011; Thatcher, 2012;), this project develops a carefully
articulated model of culture and literacy that assesses relevant and measurable variables for
connecting culture to health literacy for Spanish-speaking residents along the U.S.-Mexico
border.
As first developed by literacy scholars (Berlin, 1987; Pappen, 2009), but refined for intercultural
contexts (Thatcher, 1999, 2012) using intercultural models (Hofstede, 2010; Hampden-Turner,
2000; House et al., 2005), the intercultural literacy model is a universal framework of relevant
variables that embeds cultural differences and similarities within that frame. First, the model
shows literacy and culture in a four-part layered relationship. As shown below in Figure 2 on the
left, the center of the model is the conception that a culture develops of the self or human being.
This conception of the self, in turn, constructs or reinforces distinct thinking or cognitive
patterns, and these cognitive patterns construct appropriate social behavior. All three categories
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Theoretical and methodological approaches
correspond to distinct literacy patterns. And finally, the literacy patterns simultaneously
reinforce or re-create the previous three categories, as shown by the arrows.
Figure 2. Culture and literacy model in a comparative frame (Thatcher, 2012).
In this onion model, the inner layers are also implicit or unseen, while the outer layers are
explicit, but the logic of the outer layers exhibit the deep logic of the inner layers and vice versa.
In this universal frame, cultures can then be compared across the four layers as shown in the
comparison of the fotonovela and Anglo-generic pamphlet on the right side (Thatcher, 2012).
Further, this model is particularly effective for intercultural rhetoric because it shows how tacit
or unconscious values systems are related, and how and why they surface in communication
patterns. This is what many intercultural scholars have labeled as the iceberg theory (Hoft,
1995): Only 10% of an iceberg shows above the water, with the remaining 90% below the
surface. Likewise, the communication patterns are usually the only tangible manifestation of
deeply rooted, yet hidden conceptions of the self, thinking patterns, and social behavior, and
thus, a miscommunication is not simply an improper transfer of information. A
miscommunication implies a deviation from the target audience's conception of humanity, of
thinking, and of appropriate social behavior. For example, as I have often experienced in Latin
America (Thatcher, 1999), a person coming from an individualistic culture (such as the United
States) will most likely draw upon direct, more objective and analytical, and openly agonistic
communication patterns, which are not only misunderstood by those from more collective
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For intercultural rhetoric researchers, this connection among the four layers is important because
we can observe the social behaviors and the rhetorical patterns, and from most patterns, we can
infer the epistemologies and definitions of the self. Consequently, we can infer the implicit
inside layers from the explicit outside layers of social behaviors and rhetorical patterns. For
example, we can understand the conception of the self or epistemology based on the observable
social or rhetorical behaviors. This inference, connecting the explicit to the implicit values, is
critical in developing intercultural competence. However, the rhetorical patterns are much like
genres—oversimplified patterns that belie the complexity of the cultures that create them. Thus,
we must not equate the generalized patterns with the behavior of the culture that is responsible
for those patterns, a deductive stereotype (Bennett, 1998).
cultures, but are deeply offensive because they contradict the interdependent and collective self,
thinking patterns, and social relations. Thus, a miscommunication can strike a discordant chord
at the very essence of the cultural values of the target audience.
This model of culture and rhetoric is useful for health literacy researchers because it
demonstrates how to compare two rhetorics from different cultures. Essentially, researchers
compare how different definitions of the self, thinking patterns, and social behaviors create
specific forms of communication, and as a result, researchers can match the communication
forms to these specific patterns. Much intercultural research has documented different
conceptions of the self, thinking patterns, and social behaviors, which is summarized below in
the discussion of eight intercultural value sets. This value-set comparison places the cultures on
as equal standing as possible (see Thatcher, 2001; 2006; 2012) where researchers start by
recognizing similarities based on shared contexts and then by considering differences within the
framework of these similarities (Bhawuk & Triandis, 1996; Lucy, 1996). Embedding of
difference in a framework of similarities, because it works against analyzing a second culture
using the cultural constructs of the first culture, such as seeing an apple only in light of the
orange (Bhawuk & Triandis, 1996).
As another key strength, this model allows researchers to draw on existing methodologies,
variables, units of analysis, and cultural data developed by cross-cultural researchers (House, et
al., 2005; Hofstede, 2010; Hampden-Turner & Trompenaars, 2000; Triandis, 1995; Hall, 1983,
1976). As shown in Table 3, each layer of culture corresponds to two variables/units of analysis:
Intercultural communication and organizational behavioral researchers have been using these
value sets for more than 30 years, while health researchers are just beginning to notice their
usefulness (Meeuwesen, et al., 2009).
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Table 3
Variables and units of analysis integrated into literacy-culture model.
Variables
What Variables Measure/Units of Analysis
IndividualLevels of independence or interdependence among groups of
Sense of
Collective
people.
Self
Status/Achievement Sources of status, pertaining to actions versus backgrounds.
How rules are developed in universal versus particular
Thinking Rules Orientation
application.
Patterns
Public-Private
Crossing from public to private based on relations and context.
sphere
Inner Outer
Where people look for virtue and guidance for their behavior.
Social
Behaviors directed
Poly or Mono Time Affinity for simultaneous or linear time.
Context in
Relevance and influence of context in communication.
Literacy
Communication
Patterns
Power Distance
Influence of inequality in interpersonal communications.
Using these variables, we can now clearly assess the cultural differences between the fotonovela
and the generic pamphlet. As explained fully elsewhere (Thatcher, 2012), the fotonovela and
pamphlet exhibit clear cultural and rhetorical differences.
Individual/Collective
First, the two pamphlets assume differences between the individual and collective orientations.
In the fotonovela, that there is a strong collective orientation, which meets the predominant
values of most Latin American countries, including Mexico. The entire health scenario is
grounded in the Ramirez family, including the specific roles of grandmother, father, mother, and
the two children. The first page of this pamphlet does not define cardiovascular health; rather
the first page lays out the family as the context for this discussion. And members of this family
are not seen as independent equals, a characteristic of individualistic cultures; rather each
member of the family is seen in a specific, traditional role with their corresponding hierarchies,
further reinforcing the collective orientation of the pamphlet.
On the other hand, the generic pamphlet shows strong patterns of individualism. The first page of
the pamphlet shows a lone individual isolated from social context. There is no grounding in a
specific time, place, context or social relations; rather, there is a strong emphasis of an objective
analysis of cholesterol levels, divorcing these levels from anything other than the individual
uniqueness. In addition, the figure of the lone person running in light of the heart and the
checklist emphasize personal achievement and self-creation. There is a friendlier document
design pattern, which allows individuals to quickly locate desired information. On the other
hand, the document design of the fotonovela is not as reader friendly, from U.S. cultural
standpoint, because it is designed around the social interaction, not the information that needs to
be presented to the user.
Rules orientation
The generic pamphlet demonstrates strong universalist tendencies. First, it focuses on defining
cholesterol levels for everyone, notwithstanding their social or personal situations. In addition,
this pamphlet presents objective information, which emphasizes the scientific and universal
nature of health and cholesterol. Third, this pamphlet presents much of the information in the
form of lists, a universalist strategy that emphasizes the parallelism and readability needed for
universalist readers. And there is a general layout that carries throughout the whole pamphlet.
Fourth, this pamphlet has much more muted or less dynamic colors. Finally, this pamphlet
presents the process of determining appropriate cholesterol levels very differently than the
fotonovela. In this manual, the process is overt, shown by the calculator and the tables used to
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Both pamphlets exhibit universal and particular traits, but in each one, one value orientation
greatly predominates. In the fotonovela, particularist communications predominate. First, there
is uniqueness in the page design, for each page has a different layout based on the particular
visual and verbal information needs. Second, there is no parallel information or lists. Third, and
most importantly, the rules or subject of cardiovascular health are discussed in light of the
specific relations and context of the Ramirez family. And the rules change according to the
circumstances because the arrival of the boyfriend raises the blood pressure of the father, a
classic particularist approach to rules. Thus, the fotonovela argues for improving the
cardiovascular health for the benefit of the whole family.
calculate the different levels of cholesterol. This overt process further reinforces the universal
approach.
Sources of virtue and guidance
The logic of the fotonovela is outer-directed (Hampden-Turner & Trompenaars, 2000) because
its reason or logic for controlling cholesterol and improving heart health is not analytical or
vertical, universally breaking down the parts into its whole. Rather it is what Stewart and
Bennett (1991) label as horizontal and relational, focusing on the context or the what and its
relations rather than the why. This outer-directed approach connects the health of each of the
family members together in their home with the father as the head. These horizontal connections
have less to do with the actual cholesterol levels of each of the persons and more to do with the
combination of what they eat and how they relate to each other in this specific context. From
this perspective, one looks to harmonize himself or herself with the world. This harmonizing
logic is very powerful and often uses analogies and metaphors of the natural world as logical
patterns to replicate.
On the other hand, the logic and inner directed culture focuses on the vertical why, which is often
analytical and universal which is strongly reflected in the second pamphlet. This pamphlet
emphasizes the analytical and cause and effect connections between cholesterol level and health.
Because bad health is connected to high cholesterol, if a person eats foods lowering cholesterol
and then measures his or her cholesterol, that person can control his cholesterol, which in the end
will improve his or her health. This rational and universal approach assumes a person who has
an inner will or conscience that can control what enters his or her body so as to improve health of
the body. This reflects the analogy of deep or vertical thinking, which is an important
characteristic of inner direction (Stewart & Bennett, 1991).
Public/private and degree of involvement
On the other hand, health for the generic pamphlet is broken up into very specific topics and
people, such as doctors, prescription drugs, age, gender, and other concrete components of the
person, but never are these concrete or specific topics or issues brought together into a whole;
rather they are discussed individually. In addition, instead of showing a concrete person or
family with names and the context, the second pamphlet shows an icon of a person. Thus, this is
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The two pamphlets reflect these differences in specific and diffuse communications (Thatcher,
2012). As exemplified in the fotonovela, diffuse communication patterns demonstrate that any
topic of discussion must situate the whole person in all his or her aspects and dimensions,
including social hierarchies and context. Thus, the first thing that is introduced in this fotonovela
is not a definition of good cardiovascular health; rather the first thing that is discussed is the
family and their names and their roles. Consequently, the health of the family is holistically
grounded in their relations, their diet, and their home. This multidimensional, but indirect,
approach shows that persuasion does not require salesmanship, but rather a long-term
establishment of interconnected, interpersonal values. Thus, as shown in this pamphlet, the
diffuse patterns about cardiovascular health seem (to specific people) to be hidden in the drama
of the family, circling around the point of cholesterol, because diffuse communicators need to
understand the whole person before getting to the point.
not a person they are talking about, but this is a part of a person that is seen only in its relation to
cardiovascular health, a perhaps extreme example of a specific communication strategy. The
generic pamphlet also gets at the topic very quickly, with a bulleted introduction as a caption in
the left hand corner and then announcing the topic directly in the first line.
Status
The fotonovela emphasizes ascriptive variables on the first page, listing the people in the
Ramirez family according to their ascriptive hierarchy. The father is first, then mother,
grandmother, and children. In addition, the development of health is not carried out through an
objective doctor and overt processes; rather the development of health is carried out through the
ascriptive roles and familial processes of the father, the mother, a grandmother, and the children.
Each one has a role in this process. Thus, the familial roles and processes handle the health
issue. This is very similar to the family-run business, which is very common in ascriptive
cultures because it takes ascriptive power to get things done. On the other hand, the generic
pamphlet carries out the development of health through quantifiable data and overt medical
processes, emphasizing tangible markers or milestones of good health. From this perspective,
developing good health is like running a business based on equal opportunity employment
guidelines; that is, the roles and processes are based on verifiable, visible, and rationalized roles
and processes that do not depend on ascriptive (illegal) variables.
Context
On the other hand, the fotonovela is classically high context. It communicates the message of
improving cardiovascular health through the context, not through the actual codified text. Thus,
the reader is supposed to infer the message of improving cardiovascular health through the
family’s discussion of the topic. Great attention is given to the intentions of the people,
specifically the mother in wanting what is best for her family, the father in wanting what is best
for him as the father in the family, the grandmother in her role, and the children in their roles.
These intentions are highlighted by the perpetual smiles on the characters’ faces and the positive
language of the captions. In addition, the general outline or organizational patterns of the
pamphlet is not topic based, but rather contextual or narrative, using the story to signpost the
major sections of the pamphlet. In addition to these organizing strategies, much more detail is
given to the context of where this happens, such as the house, the actual food being prepared, the
details of the names of the people, and the events surrounding the topic. There is much less
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These two pamphlets exemplify low and high context communication (Hall, 1976) strategies. For
example, the generic pamphlet is dumbed-down to the point that almost any reader could
understand it based on how concretely it codes the message into the language itself. Thus, there
is little or no reliance on the context to understand what this message means in the lives of the
readers. Secondly, there are many visual and verbal strategies that serve as signposts to guide the
reader through the text. These include lists, boxes, small graphics and icons, lines across the
page, and other ways to carefully guide how the reader processes the information. In addition,
there is very specific text that can be used to accurately quantify levels of cholesterol risk, an
approach that is highlighted by using the calculator icon. There is also attention to detail,
including the different types of cholesterol, the different risk rates, and other concrete, and
decontextual information. There are also many lists and much parallelism.
technical detail in the fotonovela because these details, in the appropriate context, will be worked
out.
Monochronic and polychronic time
The two pamphlets exemplify the differences in monochronic and polychronic time frames (Hall,
1983). Because the fotonovela uses the narrative or story to make its point, it manages to 1) tell
the story while at the same time 2) describing high cholesterol, 3) the dietetic connection to high
cholesterol, 4) the role of stress and high cholesterol, 5) the connections between age and gender
for high cholesterol, and 6) how to reduce high cholesterol to improve health. This is a complex,
polychronic orchestration of health, cholesterol, and the Ramirez family. In addition, as
explained in the Rules Orientation section, the layout of the fotonovela is particular in that each
page has its own page design showing the captions, which reflects the multitasking or
simultaneity of the Ramirez family, further emphasizing the polychronic or simultaneity of the
pamphlet.
The generic pamphlet is much more linear. It has a listed introduction on the first page, and this
introduction lays out the exact order of the pamphlet's organization. There are clear distinctions
between each section, often highlighted by different colors or a line across the page. There are
caption boxes to explain different sections, thus highlighting the different time frames. Each unit
of information and is clearly differentiated either visually or verbally. And, as explained in the
discussion of logos, the second pamphlet highlights the linear cause and effect of cholesterol
intake relating to cholesterol indices, both of which directly lead to health indicators.
Power distance
The second pamphlet shows no authority among people. Rather it explains the information to
readers who seem like intelligent, but uninformed equals in terms of authority. This low power
distance approach is carried out through the other intercultural strategies such as low context
communication, universalism, and achievement orientation. In addition, these four cultural
values–low context, universalism, achievement, and low power distance–help the second
pamphlet achieve this strategy of a user manual, one that gives the readers independence for
themselves in understanding their specific heart help situation and empowering them to make
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The power distance (Hofstede, 2010) is evident in both pamphlets, but perhaps in a more implicit
or underlying way. First, the fotonovela clearly shows the power channels of communication.
The grandmother, affectionately called Doña Fela, is the matriarch and an important leader of the
Ramirez family. Doña is an honorific or dignified title, with no English equivalent, but it
roughly means a dignified madam. As the mother of the father in the family, Doña Fela has
strong authority in this family, especially over her son, the next in line in authority for the family
context, although her authority is masked by the motherly or Virgin-Mary like strategies that are
so common in Mexican households. These strategies include self effacement but also great care
for the general welfare of others. Mariano, the father is the benevolent leader, and his wife,
Virginia, speak to her in loving but very respectful and careful ways. The children are careful
never to disrespect their parents or their grandmother. Thus, the lines of authority in the
communication are not broken. There is no authoritarianism in the fotonovela, which can happen
in less benevolent social situations.
their calculations of their health risk and corresponding corrective behavior that the readers can
carry out independent of the manual itself. This independence is not evident in the fotonovela
and demonstrates the strong connection between manuals and the four corresponding value sets.
Thus, it is not surprising that instructional manuals originated–and are very common–in cultures
that are low context, universalist, achievement oriented and low power distance.
In short, these two pamphlets exemplify how culture and communication patterns are related.
And thus, they provide a guide for designing health materials based on the cultural
characteristics of the target audience. But how well does this process work? Can we anticipate
the cultural expectations of a target audience based on our best assessment of that audience’s
cultural characteristics? This study seeks to test this model on a project of health literacy carried
out on the U.S.-Mexico border. This project developed a fotonovela for maintaining septic
systems as a way to improve health and well being of Spanish-speaking residents on the border.
The project team compared the fotonovela to a generic, Anglo-dominant design developed by the
EPA.
Project work plan
The project team researched, developed, and carried out environmental health literacy projects
relating to septic system use and water sanitation in two west Texas colonias. It was sponsored
by a grant from the Texas Center for Elimination of Disproportionality and Disparities. This
section describes the development of the training, its community-based research approaches, and
its evaluation. The last section discusses the research results, including implications for border
health literacy research and practice.
Project deliverables: Fotonovelas, teatro, and community engagement
The project team developed culturally and linguistically sensitive training materials (in Spanish)
for use and maintenance of septic systems and water sanitation for colonias in West El Paso
County and in Ft. Hancock (Hudspeth County). These materials served as a starting point or pilot
program for use in other colonias (see final version of fotonovela in Appendix A). The materials
were developed in conjunction with community leaders and distributed to colonias residents and
to local county and state authorities who oversee sewer/water issues in the colonias.
The first part of the project was to develop fotonovela like the heart health one described earlier
in this article. This fotonovela became the basis for the development of a community
presentation and question and answer session, another important mechanism for disseminating
health and environmental information for US-Mexico border communities. Using communitybased approaches, the team produced 500 Spanish booklets for sewer and water sanitation.
During the community presentation, the project team trained specific community leaders in
inspecting the septic systems. This training helped solidify the capacity and knowledge of the
community leaders.
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This training used a family approach with a grandmother caring for her grandchildren while the
mothers and fathers were working, a theme strongly suggested as common and important by the
community leaders in Fort Hancock and West El Paso.
Training sites and populations in border colonias
The U.S.-Mexico border region is home to around 2,000 colonias, which are low income,
unincorporated rural subdivisions characterized by substandard housing, inadequate plumbing
and sewage systems, and limited access to clean water. Although colonias are found in all U.S.
border states, most them are located in this El Paso del Norte area and along the Big Bend area in
southeast Texas.
A typical colonia is a 2 acre parcel of land with 8-12 hand-made cinder block houses or mobile
homes or a 1/3 acre lot with three or four homes. There is no systematic planning for water and
sewer, and many do not have potable water or sufficient land per septic system to ensure
adequate septic functioning. Some homes share the same septic system or have open cesspools.
The Border Environmental Cooperation Commission estimates that 150,000 households in
colonias are still lacking basic sewer and water infrastructure
(www.cocef.org/files/Analisis_Final/White Paper Analysis of US-MEX Border Program.pdf).
In addition, most colonias have unsafe home construction, are often in floodplain locations, have
poor educational opportunities, limited social networks, and no electricity or paved roads.
Most research finds that virtually all colonias residents are Hispanic with an average annual
income of less $5,000. Many have a large contingency of immigrant and migrant workers, along
with their families, which are predominately monolingual in the Spanish language.
Figure 3. Map of Colonias in El Paso County (source:
www.hud.gov/local/tx/groups/coloniasaz.cfm)
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The research and development of the fotonovela took place in Fort Hancock, while the
community training took place in East El Paso County. As shown below in Figure 3, the
colonias in El Paso County are concentrated in the southeast and northeast. The community
meeting took place in the cluster signaled by the red box where there are around forty other
colonias representing around 700 occupied lots and perhaps more than 1400 households and
3,000 residents. (www.epcounty.com/planninganddevelopment/images/water2-unserved.pdf).
In Fort Hancock, the training took place is what is informally known as Fort Hancock East or
Colonia Esperanza. The following Figure 4, taken from Google Earth, shows the small area of
Fort Hancock on the left or west side, and the area in the rectangle is Colonia Esperanza.
Figure 4. Colonia Esperanza.
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The following is a selection of pictures in Colonia Esperanza, which generally indicate typical
colonia characteristics in West Texas. Photographs were taken by Kallie Malcom, an MA
photography student from NMSU who accompanied members of the project team on the
research trips as a way to document the colonia.
Research and development activities
The project team originally planned to carry out the work in two colonias: Colonia Revolución in
East El Paso County and Villa Alegre, which is part of Fort Hancock. The team contracted a
local health promoter, Enrique Cervantes (pseudonym) who lives in East El Paso County, next to
the grouping of colonias shown earlier. Cervantes is bilingual and a student at El Paso
Community College. We also contracted with Patricia Gonzalez (pseudonym), a long-time
resident of Fort Hancock East. Cervantes first went to Colonia Revolución and quickly
discovered that this colonia had received training in septic systems and even had rudimentary
training materials. Thus, the project team re-focused their attention on Fort Hancock.
Upon discussing the project further with Patricia Gonzalez, the project team discovered that all
of Fort Hancock East, a total of about 150 residents, had no central sewer systems and
problematic water systems. Gonzalez lives in this area and knows firsthand the issues of septic
and water. Originally, we had contracted Gonzalez to carry out the work in Fort Hancock and
Cervantes, the work in east El Paso County. Meanwhile, Gonzalez obtained full time
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Planning initial needs assessment
employment but volunteered to help the project team carry out the work there. Cervantes, with
the careful guidance of Gonzalez, then carried out the initial needs assessment there in Fort
Hancock.
Enrique Cervantes was carefully trained in septic systems and general health and social
indicators. He then began his work in Fort Hancock East, going door to door talking to the
residents about their quality of life as connected to water, sewer, and health. Cervantes visited
100+ households in six different trips to Fort Hancock, carefully documenting what he saw and
what the residents told him about their water, sewer, and health conditions.
Results of needs assessment in Fort Hancock East
First, the residents of Fort Hancock East are almost completely unaware of their septic systems,
how they functioned, and how they are to maintain them. About 1/4 of the residents surveyed
were born in the United States and 3/4 in Mexico, although all of them are residents of this
border area—either on the U.S. or Mexican side. As a group, there is little common knowledge
of septic systems as anticipated.
A major problem discovered in this comprehensive needs assessment is the water rate for this
colonia, which averages almost 18 dollars per 1000 gallons, nearly nine times the average rate of
around two dollars per 1000 gallons. Patricia Gonzalez, for example, showed us her monthly
water bill of 90 dollars for just over 4,000 gallons, a very, very small usage of water. She has no
plants to water, has one person living in her house, and watches her water carefully.
Enrique Cervantes also assessed the residents’ knowledge of septic systems and, not surprisingly,
concluded that we need a basic training on fotonovelas that is contextualized in Fort Hancock.
Pati Gonzalez suggested using a grandmother and grandchildren as a frame for the fotonovela,
based on the makeup of many residents in Fort Hancock East.
Table of contents and objectives for training
Based on the project proposal submitted to the Texas state agency, the project team developed
the following content for the fotonovela:
The project team then created a story board about a grandmother who is worried about her septic
systems because of the health problems of a grandchild. Thus, the team combined the fotonovela
or soap opera frame for the planned content.
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▪ Understanding and identifying the specific location and design of septic systems in the
property.
▪ Understanding local septic system regulations.
▪ Contracting with installers to correct problems or improve systems.
▪ Understanding what wastes can be safely disposed into the septic systems.
▪ How to properly treat and have septic systems pumped.
▪ How to identify failures in systems.
▪ How to facilitate communication between appropriate government authorities and
colonias residents on septic issues.
Pati Gonzalez, the Fort Hancock health promoter then secured an agreement with her neighbor to
take pictures for the fotonovela on hers and Pati’s property. As shown by the final version of the
fotonovela shown in the appendix, this person played the grandmother, Enrique Cervantes played
the son, and a local friend played the grandchild. We received informed consent from all the
people to take these pictures. The project team then took pictures on two occasions to form the
foundation of the fotonovela.
Creating the fotonovela
The project leader, Thatcher, then drafted a manual with the story board, created the manual
design, uploaded and edited the pictures for use in the fotonovela, and created the first draft of
the fotonovela. Thatcher used an EPA manual, translated into Spanish (shown in Appendix B),
as a general guide for the fotonovela technical content and Spanish terms; but he worked
carefully with Cervantes and Gonzalez to use language and forms of expression that are common
for the colonias in this area.
Thatcher distributed the fotonovela to the health promoters, Cervantes and Gonzalez, to the
Border Colonias Workgroup, and to other bilingual stakeholders. All provided feedback, helping
Thatcher refine some word choices. Thatcher thus produced what the team calls the research or
test version of the fotonovela.
Collaboration with the Border Colonias Workgroup
The project team, organized under the non-profit Border Environmental Health Coalition
(BEHC) carried out this work in close cooperation with members of the Border Colonias
Workgroup, a group that recently has focused significant resources on border Colonias. Members
include: Dr. Marcelo Korc, Pan American Health Organization; Gina Posada and Victor
Valenzuela, Texas Commission on Environmental Quality; Kathryn Hairston, Ombudsperson,
Texas Secretary of State; Yuri Orozco, Public Health Improvement, Texas Department of State
Health Services; and Adriana Corona Luevanos, Office of Border Texas Health, Department of
State Health Services. The objective of the workgroup is to prepare, coordinate the
implementation, and assess annual inter-institutional action plans to reduce the health risks in the
most threatened and vulnerable Colonias of El Paso and Hudspeth counties following the
mission and roles of each participating institution.
BEHC carried out the research and development of the project, but the Border Colonias
Workgroup provided supervision, technical expertise, and agency and institutional support.
The research and development of the fotonovela and community meeting followed the welldeveloped processes of participant-based research and community development. The Colonias
Work Group had already developed important relations with the two colonias and had already
held community meetings. The two colonias had already identified water and sewer as their most
pressing social, economic, and health issues. Thus, the project team met with the colonias leaders
in coordination with the Colonias Work Group. The project team proposed tentative table of
contents, based on existing research, but the team asked the community leaders to critically
discuss the table of contents and the development of the fotonovela.
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Community-based approaches
Further, it was decided, based on community input, that a community meeting, instead of a teatro
would be bested suited, for two reasons: First, the fotonovela itself mirrors or mimics the teatro,
so in effect, we carried out a teatro during the oral presentation. Second, the participants felt that
the topic of the project–septic systems– would be difficult to present in a teatro and not many
people would show up. The following Table 4 summarizes how this reciprocal relation worked;
the three communities are listed in across the top row and the stages and intervention processes
are listed in first column.
Table 4
Summary of integrate project approach.
Methods
Development
and
Instrument
Validation
Data
Gathering
Data Analy/
Results
Training
Design and
Implementat
ion
Training
Evaluation
Action Plans
Critical
integration
of experience
Project Team/BEHC
Connect colonias health
problems to environmental
health literacy
Assess community base of
knowledge and how to raise
base knowledge to achieve
desired procedural outcomes
Create valid research
approaches and instruments
that are integrated into
community methods and
culture
Partner in gathering data and
speaking for communities.
Partner in analyzing data and
reporting results
Create training approaches
that are connected to research
results and integrated into
community methods
▪ How effective was training
in meeting cultural and
linguistic expectations and
needs of population (CLAS)?
▪ How can results be
replicated in other similar
health literacy contexts?
▪ How are health literacy skills
to be further developed in this
population?
▪ How does this research
reveal new insights and
strategies into health literacy
theory and practice for U.S.Mexico border populations?
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Problem
Identification
Needs
Analysis
Integrated Community-Based Research Logic
Colonias Residents in West
Border Colonias Workgroup
Texas
Identify health problems related
Connect colonias health
to water sanitation and sewer
problems to SDOHs and
policies and infrastructures
Identify community knowledge of Prioritize knowledge and
water and sewer problems in light procedural gaps to form most
of economic, infrastructure, and
addressable and urgent needs
cultural realities
Identify community methods of
Connect community methods
education and literacy,
to WHO’s “Core questions on
emphasizing cultural roles of
drinking-water and sanitation
mothers, fathers, and children
for household surveys” and
other valid methods.
Partner in gathering data and
Oversee data gathering in light
speaking for communities
of research and policy
Partner in analyzing data and
Oversee data analysis/results
reporting results
in light of research and policy
Identify and make visible
Connect community methods
community methods of training,
to research results and
emphasizing cultural roles of
validated training approaches
mothers, fathers, and children
and processes
▪ How well does the training meet ▪ How well does training
their everyday needs?
meeting address the SDOHs?
▪ How much do the new
▪ How can the training be
behaviors improve their health?
replicated in similar contexts?
▪ What concrete changes are
▪ How do changes in behavior
needed in everyday behavior?
lead to improved SDOHs?
▪ What long-term infrastructure
▪ What infrastructure needs
needs need to be addressed?
need to be addressed?
▪ How are health literacy skills to
▪ How are health literacy skills
be further developed?
connected to SDOHs?
▪ How does this literacy training
▪ How effectively are the new
improve their overall literacy
knowledge and procedures
capacity?
integrated into an overall
▪ How does this training influence health plan?
residents’ training abilities for
▪ How does this knowledge
water, sewer, and other literacy
influence state and federal
areas?
policy regarding SDOHs?
This equitable and strategic partnership shared the power, resources, knowledge, and results and
fosters a mutual but critical understanding and appreciation of each partner's knowledge and
skills at each stage of the project. This approach naturally facilitates a cyclical process of
research, action, and critical integration for all three communities.
Preference research of fotonovela versus EPA manual
Following a long line of well developed research in organizational behavior (Hofstede, 2010;
Hampden-Turner & Trompenaars, 2000) and intercultural technical communication (Thatcher,
2012), the project team decided to test the preference of the colonia residents, having them
decide if they liked the fotonovela format better than the traditional linear, written, and topicbased format of an EPA manual. As shown in Appendix B, the EPA manual follows all of the
cultural and communicative patterns that are predominant in the United States, while the
fotonovela—at least theoretically—follows the cultural and communicative patterns common in
Mexico and Latin America. In other words, the fotonovela is assessed as more collective,
ascriptive, particular, diffuse, inner-directed, polychronic, high context, and unequal power
distance, while the EPA pamphlet exhibits the contrastive values. I hypothesized that the five
border groups would then connect to each manual based on their eight distinct cultural
orientations.
Cross-cultural learning design
Grounded in these appropriate communication strategies, the project team also used a four-stage
instructional approach for the colonias residents:
Narratives and scenarios grounding. Based on a long history of organizational culture, civil
law legal institutions, and educational practices (Albert, 1996; Kras, 1993), a predominant
Mexican approach to learning a new task or issue is by first thinking through all relevant
scenarios surrounding the task. This is especially true of low-literate or oral learners, a critical
part of the border population. This scenario grounding needs not be exhaustive, but it must be
representative and rich in detail, much like the case study approach. This has proven beneficial
in many training scenarios for Mexican factory workers working in U.S. maquilas (Thatcher,
2006).
Analysis and exceptional thinking. One of the weaknesses of using scenarios to develop
theories is that a scenario does not usually adapt well to cause-and-effect analysis and to a
judicious sense of when exceptions to the rule are important (Thatcher, 2000). Thus, participants
in this septic system instruction training will need to move their scenario theories into applicable
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Theory building from scenarios. After sufficient involvement and discussion of scenarios, the
learners need to build working theories of the proposed learning objective (Thatcher, 2006).
Theory building of this sort is best accomplished by comparing the relevant details of each
scenario and subsequently building theories from these comparisons. This kind of theory
building critically links the topic to the current context of use. This is especially useful for
comparing water and sewer systems.
cause and effect analysis, looking at which causes are linked to which effects. For example, it is
critical to link the condition of the water and sewer systems to corresponding health issues and
outcomes. This analysis also must look at weighing the significance of exceptions to the rules,
understanding when an exception is ok (see Thatcher, 2000).
Problem solving and application. Finally, the cause-and effect-analysis and exceptions
thinking need to move to concrete scenarios of problem solving and application (Thatcher,
2000). This step is crucial because the highly abstract or completely hands-on oral training,
which is common in Mexico, especially on low literature populations, works against effective
problem solving (Thatcher, 2006). Thus, an important component of the materials will focus on
problem solving and application as the final assessment of instructional objectives or outcomes.
This is the reason for the developing the teatros and modeling the testing of sewer and water
systems.
Understanding these cultural and communicative differences is critical for developing effective
instruction in septic system use and water sanitation in border populations. Instructional
materials developed in the United States will most likely exemplify U.S. communication and
instructional traditions, including what the materials are used for, how one learns from them, and
what they empower the reader to do in a specific context. Those not familiar with these U.S.
traditions will probably not understand, learn from, or be capable of doing what the U.S. authors
intend.
In short, these two pamphlets exemplify how culture and communication patterns are related for
either Latino or U.S. generic or Anglo audiences. And thus, they provide a guide for designing
health materials based on the cultural characteristics of the target audience. But how well does
this process work? Can we anticipate the cultural expectations of a target audience based on our
best assessment of that audience’s cultural characteristics? What are the preferences for Latino
or Hispanic audiences on the border? Do they follow the hypothesized values that the fotonovela
contains? If so, why?
Preference research activities
Enrique Cervantes conducted the research at 50 households in Fort Hancock East (Colonia
Esperanza). We provided 20 dollar gift cards for those households who agreed to participate in
the research. The research protocol was approved by the Institutional Review Board at New
Mexico State University. Cervantes went from house to house; he explained the research
purpose and gift card and asked the residents if they wanted to participate. All of the participants
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To answer these questions, the project team conducted a simple but powerful preference test of
50 households in Fort Hancock East, asking the residents to carefully read both the fotonovela
and EPA pamphlet, and then Enrique Cervantes guided them through an oral preference survey
where they indicated their choices. The survey is found in Appendix C. The survey contains
demographic information such as birthplace, education, gender, and age; and it asks 10 LIKERT
preference questions and 5 open-ended questions. All the questions were designed to assess the
preferences and needs of this border audience for the septic training materials.
spoke Spanish as a first language, although a few were bilingual. Occasionally, Cervantes had to
skip residents who were not capable of reading.
Cervantes entered the household, explained carefully the study, had the participants read and
sign the IRB informed consent, and then he asked them to read carefully both the fotonovela and
EPA manual. He alternated which manual the residents read first, and according to Cervantes,
the reading order had no effect on the results. After carefully reading the manuals, the residents
then were asked orally the questions shown on the survey. Cervantes took careful notes. As
explained next, the participants were all adults over 21 and ranged in age and education;
precisely ½ were born in the United States, and the other half in Mexico. All were from the
general Texas-Chihuahua area.
Research results (from 50 surveys)
Demographics
Birthplace and Education: Most were born in Mexico (38) with 35 of these in Chihuahua—the
state bordering Texas and New Mexico. 12 were born in USA (all in Texas). All birthplaces
corresponded to places of Education—nobody was born in one country and educated in the
other.
Gender: 17 men and 33 women.
Average age: 50 with many Mexican-born as older and young U.S.-born.
Languages: All reported having Spanish as first language. 35 reported having levels of either 1
or 0 in English (low or nothing); six reported having 8-10 levels of English. Except for the six
bilingual participants, participants exhibited a very low level of English.
Results for preference survey questions
The results for the questions are reported below in Table 5.
Table 5
Results of preferences survey (50 total respondents).
2. Fotonovela explains more
clearly the techniques for
inspection and maintenance.
3. The instructions of the
fotonovela are easier to
follow.
Results
47 totally agree
1 agree
2 totally disagree
31 totally agree
10 agree
5 disagree
4 totally disagree
41 totally agree
6 agree
3 disagree
0 totally disagree
Initial analysis
Overwhelming preference for fotonovela in
terms of ease of understanding.
Of the 9 who disagreed, 6 were from Texas.
All 9 had at least 5 on English level. Good
correspondence among language, preference,
and English level.
Clearly, the fotonovela is easier to follow.
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Questions
1. Fotonovela is easier to
understand.
Questions
4. The fotonovela presents
information in a form more
applicable to my situation
5. The EPA manual better
motivates me to maintain my
septic system.
6. The EPA manual contains
better information.
7. The EPA manual is better
designed.
8. The EPA manual takes
into account better my needs
as a septic system owner.
9. The EPA manual is more
professionally created.
10. I prefer the design of the
EPA manual as a form of
written training.
Advantages of the two forms
of training.
Hybrid manual.
Results
32 totally agree
11 agree
4 disagree
3 totally disagree
24 totally agree
11 agree
11 disagree
4 totally disagree
37 totally agree
11 agree
1 Undecided
2 disagree
0 totally disagree
28 totally agree
15 agree
2 Undecided
5 disagree
0 totally disagree
19 totally agree
18 agree
12 disagree
3 totally disagree
34 totally agree
7 agree
2 Undecided
6 disagree
2 totally disagree
24 totally agree
2 agree
19 disagree
5 totally disagree
Initial analysis
Clearly, the fotonovela is easier to apply to
residents’ contexts.
Seriousness of the tone of the EPA manual
seems to motive residents more.
Clear agreement that the EPA manual has
better information.
Strong agreement that the EPA manual is
better designed.
Mixed results on what meets their
expectations though slight favoring of EPA
manual.
Good agreement that the EPA manual is
more professional.
11 of 12 who preferred the EPA manual are
from Texas. Only one U.S-born participant
preferred the EPA manual. 6 who preferred
the EPA manual like its information; 5
mentioned the need for more pictures in EPA
manual but still preferred it.
Some correlation between less education and
preference for the fotonovela; more men than
women preferred the fotonovela—correlated
to higher levels of education in women.
Fotonovela needs more information; is an inferior or less serious form
of instruction. EPA manual needs more pictures.
A combination of the pictures and story from the fotonovela and
information from the EPA is what is generally wanted.
Discussion of results
The first discovery is that despite the training and urging I gave to Enrique Cervantes to make
sure the residents simply did not agree with whatever question, we believe that at times some
residents favored the strongly agree or agree answers regardless of the questions. I did mix the
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Bias control
questions, using the agree questions for the fotonovela in the first four and agree questions for
the EPA manual in questions 5-10. But there is some tendency to agree, especially with this
face-saving population.
Ease of understanding and following
The results showed a very, very strong preference for the format of the fotonovela in terms of
ease of understanding and following the instructions. This is especially true for those born in
Mexico.
Applicability and inspection techniques
Another clear preference was for residents agreeing that the fotonovela was more easily applied
to their situation, and the inspection techniques are easier to follow. Further, we see that all but
one Mexican-born and educated participant preferred the fotonovela in these categories. On the
other hand, 11 of the 12 U.S.-born and educated participants preferred the EPA manual. Clearly
birthplace and education strongly correlate with this preference.
Professionalism and information
There was a clear preference for the EPA manual in these categories, with some residents talking
about the “inferior” or “less serious” approach of the EPA manual. There might also be some
gender issues with a few men discussing the “old lady” in the fotonovela. Clearly, the EPA
manual had more verbal information, and the residents like the security that this information
brought them. However, it is interesting to note that a lot of the information that is expressed in
writing in the EPA manual is implicit in the context of the fotonovela manual. Thus, this
preference might have more to do with the more official-looking written approach, something
linked to the writing traditions of Mexico (Thatcher, 2006), which are more clearly linked to law
and business. Health and other “less serious” topics are often connected to women’s duties in
the home. More research is needed here.
Preferred format for written training
The results showed a clearly mixed response on this topic. 26 preferred the EPA manual, and 24
preferred the fotonovela as the best form of written training. However, it is important to point
out that 11 of the 12 U.S.-born residents preferred the EPA manual, and all who preferred the
EPA manual had higher levels of English. Thus, there is a strong correlation among birthplace,
education, knowledge of English and preference for which manual. The Mexican-born residents
with lower levels of English strongly preferred the fotonovela approach.
Takeaways and hybrid approaches
On the open ended questions, it was clear that the EPA manual needed more pictures and the
Fotonovela needed more information. Thus, for the final version, I integrated more written
information into the fotonovela. I also feel that perhaps involving a man in the fotonovela would
give it a more “serious” tone to some participants as well. Finally, being educated in the United
States strongly correlates with more written forms of literacy.
After finishing the preference research, the project team carefully compared the two manuals and
integrated all information from the EPA manual that was not apparent in the test version of the
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Final fotonovela, community meeting and community presentation
fotonovela. This created a more hybrid approach but still used the fotonovela organizational
design (see Appendix A).
With the final fotonovela in hand and 500 produced at NMSU’s Print Shop, we first organized a
meeting at Colonia Revolución for a trial run of the presentation. Alicia Saenz (pseudonym), a
graduate student in public health and intern with the Pan American Health Organization, assisted
in the work. Ana Mendez (pseudonym), a local promotora or health worker met with four
residents and piloted her presentation. After receiving feedback from these residents and Alicia,
she prepared her final presentation. Ana is originally from Mexico and just finished her Texas
promotora certification. This was her first official project.
The project team then organized a community meeting at the Health Clinic Juan Diego in the
colonia Agua Dulce in East El Paso County. Another promotora, Cecilia H., a long time
resident, of this colonia, aided in gathering the people.
At this community meeting were in attendance 100 heads of households, plus 20+ children. All
were native Spanish speakers and of Mexican ancestry. The presentation was given in Spanish.
Ana Mendez presented the final fotonovela on an overhead projector, taking the residents
through each page and explaining each concept and step carefully. Then Ana prompted the
residents for questions. After the presentation, Alicia distributed a short assessment for the
residents, and Ana distributed the 10 dollar Wal-Mart gift cards to the participants.
Participatory assessment of final fotonovela and accompanying presentation
As part of her internship at PAHO, Alicia created a short assessment, following the original
project proposal objectives stated earlier.
Summary of findings
The results from the assessment demonstrate that the fotonovela approach, combined with a good
question and answer session, are very effective for this target population. In almost every
question, the residents were able to answer correctly.





The highest percentage of people answered that maintaining/cleaning/pumping their
septic tank was important. [Table 6]
Most people understand that it’s the responsibility of those living in the household to
maintain their septic tank. [Table 8]
The biggest concern that people have regarding septic tanks is the risk of exposure to
diseases and infections. [Table 9]
The top three things people learned were how to maintain the septic system, to be careful
of what they flush down the toilet, and to make sure cars and trees are far away from
septic tank. [Table 13]
It seems that most people liked the explanation that was given followed by everything
about the fotonovela/presentation. [Table 14]
Page 98
The major findings are that:


About 29% of people answered that pumping the septic tank every 3-5 years was how
they planned on maintaining their septic tank. [Table 12]
More than half of those who responded to the question of whether anything could be
done to better the fotonovela, said that nothing needed to be improved. [Table 15]
Positive aspects





A larger than expected substantial sample was recruited, approximately 100 individuals.
Participants appeared representative of the community with respect to age, sex, and
socioeconomic status.
A total of 53 surveys were turned in by participants.
The large majority of participants arrived on time and appeared motivated.
Participants seemed to like the $10 Wal-Mart gift card compensation.
Limitations


Participants had nothing to write on other than their fotonovelas which made it difficult
and uncomfortable for them to fill out their questionnaires especially since many were
older.
We are not sure that all of the participants followed the directions given to them on how
to fill out the questionnaire.
Evaluation questions for water/Sanitation health education presentation
¿Qué es lo que usted piensa sobre el uso y mantenimiento de su sistema séptico?
[What do you think about the use and maintenance of your septic system?]
Table 6
Response
Important to maintain/clean/drain
Important for the family’s health and hygiene
Necessary
Important not to contaminate environment
Other
No Response/ Nonresponsive
Percent
37%
19%
9%
7%
20%
7%
No. responses
20
10
5
4
11
4
¿Qué es lo que usted piensa sobre el pago por el mantenimiento de su sistema séptico como por
ejemplo el servicio de bombeo?
[What do you think about paying for the maintenance of your septic system like for example with
the pumping service?]
Response
Willing to pay
It is expensive/Unwilling to pay
Need to have more accessible prices
Other
No response/ Nonresponsive
Percent
47%
18%
4%
8%
23%
No. of responses
24
9
2
4
12
Page 99
Table 7
¿De quién es la responsabilidad de mantener su sistema séptico?
[Who’s responsibility is it maintain the septic system?]
Table 8
Response
Mine/ those living in the household
Percent
92%
No. of responses
47
8%
4
¿Cuáles son sus preocupaciones sobre el impacto ambiental y en la salud de su sistema séptico?
[What are your worries regarding the environmental and health impact of your septic system?]
Table 9
Response
Sickness/infections
Solucionarlos (solving them)
Contamination of the environment
No den buen servicio (not good
service)
Other
Percent
60%
6%
4%
4%
No. of responses
32
3
2
2
9%
5
¿Cuáles son dos cosas que usted aprendió gracias a la fotonovela/el Teatro?
[What are two things that you learned thanks to the fotonovela/ the presentation?]
Table 10
Percent
40%
20%
13%
5%
No. of responses
24
12
8
3
5%
5%
12%
3
3
7
Page 100
Response
How to maintain the septic system
Careful when throwing things into the toilet
Watch for trees and cars near the septic tank
How to evade diseases/ watch the families
health
To be careful with the environment
Other
¿Qué le gustó más sobre la fotonovela/el Teatro?
[What did you like most about the fotonovela/ the presentation?]
Table 11
Response
The explanation
Everything
Information regarding not throwing toxins or
certain substances into the toilet
The real photographs and story line.
Other
Percent
25%
21%
8%
No. of Responses
13
11
4
8%
20%
18%
4
10
9
¿Cómo va a incorporar los conceptos y técnicas para el uso y mantenimiento del sistema séptico
en su hogar?
[How are you going to incorporate the concepts and techniques for the use and maintenance of
the septic system in your home?]
Table 12
Response
Drain the septic tank every 3-5 years
Be careful with the maintenance
Solucionarlos/ lo que debo hacer (solve
what I must do)
To be careful with the use of water
Other
Percent
29%
13%
8%
No. of responses
15
7
4
6%
15%
29%
3
8
15
Cómo podría ser mejorada la fotonovela/el Teatro?
[How can the fotonovela/presentation be improved?]
Table 13
Percent
61%
2%
4%
33%
No. of responses
31
1
2
17
Page 101
Response
It’s good
More detailed explanation
Other
Table 14
Summary of LIKERT results for fotonovela presentation.
Questions
Agree
Disagree
17 (33%)
3 (6%)
23 (45%)
18 (35%)
10 (20%)
24 (47%)
17 (33%)
8 (16%)
34 (67%)
14 (27%)
1 (2%)
32 (63%)
14 (27%)
2 (4%)
33 (65%)
14 (27%)
2 (4%)
36 (71%)
12 (23%)
1 (2%)
Strongly
Disagree
2 (4%)
Page 102
Mi conocimiento sobre el uso y mantenimiento
del tanque séptico es adecuado. [My knowledge
of the use and maintenance of the septic tank is
adequate]. No Response: 1 (2%)
Yo sé cómo usar y hacer el mantenimiento de
mi tanque séptico. [I know how to use and
maintain my septic tank].
Conozco técnicas prácticas de cómo usar y
mantener mi tanque séptico. [I am familiar with
the techniques for using and maintaining my
septic tank].
Mi entendimiento sobre el uso y mantenimiento
de los tanques sépticos aumentó como resultado
de la fotonovela/el Teatro. [My understanding
about the use and maintenance of septic tanks
increased because of the fotonovela
presentation].
No Response: 2 (4%)
Yo sé cómo usar y mantener mi sistema séptico
como resultado de la fotonovela/el Teatro. [I
know how to use and maintain my septic system
as a result of the fotonovela presentation].
No Response: 3 (6%)
Yo aprendí técnicas prácticas para usar y
mantener mi tanque séptico como resultado de
la fotonovela/el Teatro. [I learned practical
techniques for using and maintaining my septic
tank as a result of the fotonovela presentation]
No Response: 2 (4%)
Yo recomendaría la fotonovela a mis vecinos. [I
would recommend the fotonovela to my
neighbors].
No Response: 2 (4%)
Strongly
Agree
30 (59%)
Table 15
Summary of results about perceptions of fotonovela and presentation.
Questions
La calidad de la fotonovela/Teatro. [The
quality of the fotonovela and
presentation].
No Response: 4 (8%)
El contenido de la fotonovela/el Teatro.
[The content of the fotonovela and
presentation].
No Response: 2(4%)
La utilidad de la fotonovela/el Teatro
para mi hogar. [The usefulness of the
fotonovela and presentation].
No Response: 2 (4%)
Excellent
37 (72%)
Good
8 (16%)
Acceptable
2 (4%)
36 (71%)
12 (23%)
1 (2%)
36 (71%)
9 (17%)
4 (8%)
Poor
Discussion of results and implications
This perception of the EPA manual as having better information as compared to the test version
of the fotonovela also is interesting. A careful analysis of both manuals show that the EPA
manual has more concrete information about a few specific areas, but most of this information
could be inferred from the drama of the fotonovela. It is also important to point out that with the
final version of the fotonovela, which included verbal information in checklists from the EPA
manual, the participants at the community meeting found great value in the fotonovela design,
not only as a manual, but also as a way to present information on the overhead projector. 76%
percent of the respondents at the community meeting thought the quality of the fotonovela was
excellent, and 12% thought it was good, meaning that 88% perceived it as a quality approach.
The responses for the content and usefulness of the final fotonovela were very similar. The
responses about the practice of maintenance and upkeep of septic systems were slightly lower
but still showed an overwhelming positive approach. In this way, the fotonovela becomes a print
theater or teatro, which is a very popular method of imparting health information for this
population along the U.S.-Mexico border.
Page 103
Although exploratory, this research indicates some strong connections between cultural values
and literacy/communication patterns. First, when presented with the test version of the
fotonovela versus the EPA manual, 47 respondents totally agreed and one agreed that the
fotonovela was easier to read. Only two totally disagreed that the fotonovela was easier to read,
and these two respondents were born in the United States and had higher levels of English. One
of the two also commented about the “old lady” as the actress and the other about “inferior”
designs of the fotonovela. It is quite common on the U.S. border for some residents to view what
is perceived as Mexican as inferior; instead, opting for the “superior” U.S. design (Vila, 2003).
Further, when I presented these results to a group of stakeholders, three of whom were born in
New Mexican colonias (a few miles west of these colonias), they also reiterated the tendency for
some in the area to perceive something “as Mexican” as being inferior for some residents. Thus,
it seems quite clear that the initial perceptions about attractiveness or ease of reading resides with
the fotonovela design for this population.
Thus, I suggest that the perceived preference for the information in the EPA manual might have
something to do with its overall verbal design: It is crammed with lists and verbal information,
showing an overt fullness of information that is implicit in the fotonovela. In other words, if
fully tested through an experiment, it would be really interesting to see if the EPA design does
provide more information as compared to the test version; it seems obvious that the final version,
which has more verbal information, seemed entirely adequate for the 100 residents of the
community meeting.
Consequently, it seems that for this population of native Spanish speakers, mostly born and
educated in Mexico, a hybrid design of manuals might be the most appropriate. The overall
design could follow the fotonovela approach, including its connection to the eight value sets and
four instructional design approaches for this population; however, this fotonovela approach could
be supplemented with key verbal information, not only to make the fotonovela design look full of
information, but also to combat some of the perceptions of inferiority from some participants.
Further, the positive results point to the potential of the fotonovela design in both print and oral
presentation as a way to use some of the best strengths of the promotora or community health
worker but in a more cost-effective basis. As is commonly known on the border, using a local
community health educator or health worker, known in Spanish as a promotora, is the best way
to reach the community. However, the general operating procedures of promotoras is going door
to door, visiting the families and residences in their homes. Although ideal and effective, this
approach is time consuming and costly. Using the fotonovela approach delivers a similar kind of
interpersonal training, drawing on the appropriate cultural values but in much less time. For
example, the community training took less than an hour, but the results, based on the assessment,
were likely as high as if the hour-long training took place in a home. This suggests a good role
for fotonovela-designed research for this community, not as a replacement for the door to door
promotora approach, but as a cost-effective way to reach more with less, which might be
appropriate in many contexts.
Page 104
The second major result is the strong correlation between birthplace (and education) and
preference for instructional design. Only one of the 12 U.S.-born residents preferred the
fotonovela, while the other 11 preferred the EPA manual. Twenty four of the 38 Mexican-born
preferred the fotonovela, but those 15 Mexican-born residents who preferred the EPA manual
had, generally, higher levels of English. Thus, exposure to English and U.S. approaches to
pamphlets, exemplified in the EPA manual, strongly correlates to preference. This preference is
also compounded by the implicit feeling of inferiority among some of Mexican values, discussed
earlier. Consequently, when assessing the cultural and communicative expectations of the five
Hispanic/Latino/Mexican-American groups discussed earlier, it is critical to assess the
experience with English and U.S. literacy approaches, a finding that is not counterintuitive but
nonetheless, demonstrated in this study. This finding greatly complicates using demographics as
the guide, for four of the five Latino groups discussed earlier speak Spanish, but a very specific
subset, perhaps the recent immigrants and some Mexican nationals, preferred the fotonovela
approach.
Finally, the theoretical frame, using the eight variables and connecting those variables to
concrete features of manual design, seems well founded. Thus, the intercultural data provided by
an enormous body of work from intercultural researchers (Trompenaars; Hofstede; House, et al.)
is probably a good starting point for assessing the cultural and communicative expectations for
health literacy. This connection moves well beyond translation, ethnicity, or demographics and
into critical features of culture, as represented by the onion model; these include the sense of self,
thinking patterns, and social behaviors. As operationalized in the eight validated variables, these
features of culture are a powerful and productive way to assess the cultural profiles of
populations and design communications to meet these populations. As a result, we might
consider revising the 14 standards of culturally and linguistically appropriate services to include
some elements of these eight value sets. Thus, instead of arguing that services need to be
appropriate, we can include language to help health care stakeholders understand why and how
their services can be appropriate.
Limitations and further research
Of course one of the limitations of this study is based on the preference approach: we could not
test actual working knowledge of septic maintenance or whether the fotonovela approach
actually works better than the EPA approach. However, it seems clear that the perceived ease of
use and strong favorability for this approach are critical dimensions of health literacy. That is,
these residents seemed likely to find the fotonovela approach comfortable with their perceived
health literacy needs.
Page 105
Although this intercultural literacy model provides a clear perspective on the connections
between culture and communication patterns, we are very limited by the amount of data we have
on populations. In other words, census data does not account at all for these variables and the
demographics gives us a very unclear view of what we could expect. In other words, the data
from the 2010 U.S. Census would lump all five Latino/Hispanic groups into one, which does not
account for the cultural and communicative orientations of the different groups based on the
more accurate set of eight variables. However, these eight variables were developed and
validated at national levels in organizational behavior; thus, it is also difficult to expect these
national profiles to provide useful data for different cultural groups.
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Fotonovelas and Anglo designs in health communications for

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